RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX		BRANCH OF SERVICE: AIR FORCE
CASE NUMBER:  PD0900271		BOARD DATE: 20100428
SEPARATION DATE: 20060407
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SUMMARY OF CASE:  This covered individual (CI) was an Airman First Class/E3, Security Forces Journeyman, medically separated from the Air Force in 2006 after one year and ten months of service.  The medical basis for the separation was Myofascial Pain Syndrome w/Mid and Upper Back Pain. The CI was referred to the Physical Evaluation Board (PEB), found unfit for continued military service and separated at 0% disability using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Air Force and Department of Defense regulations.
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CI CONTENTION:  "I can concur that my Air Force rating of 0% for my left shoulder strain and myofascial pain syndrome with upper neck, mid and upper back pain during deployment training in support on the was inaccurate.  Prior to my rating (30%), I received at least one steroid shot, and plus numerous of visits to the provider for medication at the VAMC Campus in Montgomery and Tuskegee, Alabama.  My range of motion in my ... is slowly declining and I am losing control and feeling in it at the least opportune times. My extremities had numbness, which was getting worse by the day.  My primary care provider is setting up an appointment for me to meet with the orthopedic surgeon regarding my shoulder injury.  Finally I am enduring this syndrome in my back because there is no quick fix to correct this problem. I am constantly taking medication that is starting to affect my major daily activities.  I am currently on codeine for when the pain is unbearable.

I was granted service-connected for dental treatment without a rating.

I am 30% disabled as a result of my injuries.  I have been receiving treatments since my injuries sustained in March 2005 to the present.  I am currently in pain and discomfort."
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RATING COMPARISON:

Service FPEB	VA (2 months after Separation)	
Unfitting Conditions	Code	Rating	Date	Condition	Code	Rating	Exam	Effective	
Myofascial Pain Syndrome w/Mid and Upper Back Pain 	5099-5021	0%	20060221	Myofascial Pain Syndrome w/Neck, Mid & Upper Back Pain 
then 
Chronic Cervical Strain 	9422

then
5237	10%

then
  20%	20060620

20090402 	20060408

20081027	
No PEB Entry	NARSUM	Left Shoulder Strain	5201	20%
0% 	20060620
20081206	20060408
Proposed	
		1 NSC					
TOTAL Combined:  0%	TOTAL Combined (Includes Non-PEB Conditions):    
30% from 20060408
  40% from 20081027	
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ANALYSIS SUMMARY:

Analysis Myofascial Pain Syndrome with Mid and Upper Back Pain
The CI was involved in multiple all terrain vehicle accidents during military training and continued to have mid to upper back, neck and shoulder pain after appropriate conservative therapy.  Radiographs of her left shoulder, cervical spine, and lumbar spine were normal as was a Magnetic Resonance Imaging (MRI) of her cervical spine.  Physical examinations revealed a normal neurologic examination with diffuse tenderness to palpation in the mid and upper back, neck, and left shoulder areas.  Painful motion of the neck, upper back, and left shoulder were documented on the VA examination.  She was referred to Physical Medicine and was diagnosed with myofascial pain syndrome. 

After the Informal PEB determined the CI was unfit for continued service, she requested a Formal PEB and contended for a return to duty.  However, the Formal PEB determined she was unable to perform full Security Forces duties without limitations or restrictions.

There is no VASRD code for Myofascial Pain Syndrome so it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous.  Fibromyalgia causes widespread musculoskeletal pain and VASRD 5025 can be used to rate Myofascial Pain Syndrome.

At time of narrative summary (NARSUM) the CI was taking an antidepressant each night (presumably for pain) as well as both nonsteroidal anti-inflammatory medication and Tylenol as needed. The CI had also tried many other medications.  Her pain was present more than one third of the time and was exacerbated with increased use and by driving, sustained positions, and lifting. At the time of her VA Compensation and Pension (C&P) evaluation she was taking Tramadol as needed and reported this helped her pain. The CI reported she was working as a security personnel but was seeking another type of employment because the physical requirements of her job affected her pain. 

Cervical
Movement	Normal ROM	Separation Date: 20060407	
		MEB Exam 20051214	C&P 20060620
	C&P 20090402 
 (with repeated motion)	
Flex	0-45		20 (loss of 5 degrees w/repetition due to pain & fatigue	0-30 (20 )	
Ext	0-45		25 (loss of 5 degrees w/repetition due to pain & fatigue	0-30 (20 )	
R Lat flex	0-45		25 (loss of 5 degrees w/repetition due to pain & fatigue	0-30 (20 )	
L lat flex	0-45		25 (loss of 5 degrees w/repetition due to pain & fatigue	0-30 (20 )	
R rotation	0-80		45	0-40 (30 )	
L rotation	0-80		45	0-40 (30 )	
TOTAL	 (340=VA normal)		185	200 (140 )	
Notes:		- Diffusely tender to palpation of mid and upper back with no focal point tenderness of the thoracic or cervical vertebrae
- Full range of motion all extremities and forward bend	- Normal Cervical Spine X-rays and MRI 20050223	- Increased weakness, incoordination and increased palpable muscle tautness of her cervical spine as a result of repetition
- Increased fatigability
- Additional 10-degree loss in range of motion of C-Spine as a result of repetitions (Combined ROM 140)
-Normal neurologic exam
-Cervical x-ray: Slight hypertrophy of the superior articulus process of T1	
Thoracolumbar
Movement	Normal ROM	Separation Date: 20060407	
		MEB Exam 20051214
ROM measured by PT 20051205	C&P 20060620
	C&P 20090402
 (All moderate limitation due to pain)	
Flex	0-90	85, 90,90		40	
Ext	0-30	35, 40, 35 (30)		10	
R Lat flex	0-30	35, 35, 35 (30)		20	
L lat flex	0-30	35, 35, 30 (30)		20	
R rotation	0-30	35, 35, 30 (30)		20	
L rotation	0-30	35, 30, 30 (30)		20	
TOTAL	 (240=VA normal)	235 or 240		130	
Notes:		- Diffusely tender to palpation of mid and upper back with no focal point tenderness of the thoracic or cervical vertebrae
- Full range of motion all extremities and forward bend	- Normal Lumbosacral Spine X-rays	- Increased weakness, incoordination and palpable muscle tautness of her lumbar spine as a result of repetition but no additional loss of ROM
-Normal neurologic exam
-Lumbar x-ray: straightening of the lumbar spine from muscular spasm is noted; Normal sacroiliac joint.
 -Thoracic x-ray: within normal limits.	

Analysis Left Shoulder:
The CI’s profile did not restrict any overhead work as would normally be done for functional limitations of the shoulder. The profile did include no lifting but did not specifically mention lifting overhead. On the initial C&P examination the CI reported that she had difficulty lifting overhead and that lifting aggravated her shoulder pain. However there was no mention of this interfering with required duties in her service treatment record.
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BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. After careful consideration of all available information the Board unanimously determined that the CI’s condition is most appropriately rated at 20% for 5099-5025 Myofascial Pain Syndrome with Mid and Upper Back Pain.

The CI had pain that was present more than one-third of the time and is exacerbated by increased activity and is helped by medication taken as needed. This warrants a 20% rating under 5099-5025.

The Board also considered the condition of Left Shoulder Strain and unanimously determined this condition was not separately unfitting at the time of separation from service and therefore no disability rating is applied.
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RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation.

UNFITTING CONDITION	VASRD CODE	RATING	
Myofascial Pain Syndrome with Mid and Upper Back Pain	5099-5025	20%	
COMBINED	20%	
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090331, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.

PDBR PD-2009-00271

MEMORANDUM FOR THE CHIEF OF STAFF

	Having received and considered the recommendation of the Physical Disability Board of Review and under the authority of Section 1554, Title 10, United States Code (122 Stat. 466) it is directed that:

	The pertinent military records of the Department of the Air Force relating XXXXX, be corrected to show that the diagnosis in her finding of unfitness was myofascial pain syndrome with mid and upper back pain; VASRD code 5025; rated at 20%.